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2. 

4. The San Bruno Police Department offers a voluntary registry designed to help police staff better serve individuals who may have developmental disabilities, medical conditions, or other vulnerabilities. This program allows family members, caregivers, or individuals to share important information - such as communication preferences, behavioral triggers, medical considerations, and emergency contacts - that can assist our officers during interactions.

   Information provided through the registry is securely maintained, kept confidential, and may be accessed by responding San Bruno personnel to improve communication, support de-escalation, and ensure a more informed and compassionate response during emergencies or contacts.

   Participation is completely voluntary and intended for individuals who may benefit from having this information available to first responders.

8. Person Registering Vulnerable Person
10. First Name*
11. Last Name*
12. Email Address
14. Address*
16. City
17. State
18. Zip Code
20. Phone Number*
21. Cell Phone Number
23. Relationship to Vulnerable Person
27. Vulnerable Person's Information
29. Section 1 - Contact Information
31. First Name*
32. Last Name*
33. What name does this person prefer?
35. Address*
37. City
38. State
39. Zip Code
41. Phone Number
42. Cell Phone Number
44. Living Arrangement

    1. Alone
    2. With Family
    3. With Roommates
    4. Institution or Facility
48. Section 2 - Identifying Information
50. Race
    -- Select One --African AmericanAsianCaucasianHispanicMiddle EasternNative AmericanPacific Islander
52. Date of Birth
    Date of Birth
53. Height
54. Weight
56. Hair Color
57. Eye Color
59. Upload a photo of the vulnerable person (should be of good quality)
63. Section 3 - Medical Information
65. Dentures

    1. Upper
    2. Lower
    3. Both
    4. N/A
66. Hearing Aids

    1. Left Ear
    2. Right Ear
    3. Both Ears
    4. N/A
67. Visual aids

    1. Contacts
    2. Glasses
    3. N/A
69. Any visible identifying marks (amputations, deformities, scars, tattoos, etc.)
71. Diagnosis
    -- Select One --Alzheimer'sAspergersAttention Deficit/Hyperactivity DisorderAutismBlind/Low Vision/Vision ImpairmentCerebral PalsyDeaf/Hearing Loss/Low HearingDementiaDown SyndromeEpilepsy/SeizuresHuntington DiseaseIntellectual DisabilityMental IllnessOther Brain IllnessOther Developmental DisabilityOther Mental DisabilityPhysical DisabilityPTSI
72. If other disability, please explain
76. Section 4 - Location Information
78. Is there a history of prior wandering?

    1. Yes
    2. No
79. Does the person have a GPS device?

    1. Yes
    2. No
81. Previous and/or favorite locations to go to or visit
85. Section 5 - Communication Information
87. Is the vulnerable person non-speaking?

    1. Yes
    2. No
88. Will the person respond to being called by their name?

    1. Yes
    2. No
90. Preferred communication mode
91. Languages spoken
95. Section 6 - Behavior and Trigger Information
97. What is the best way for police staff to approach the vulnerable person?
98. What type of behavior should police expect? (Avoidance, non-responsive, stimming, running away, self-harm, aggression, etc)
100. How does the person feel about police?

     1. Like
     2. Dislike
     3. Neutral or no strong feelings
101. Does the person respond negatively to bright lights, loud noises, or sirens?

     1. Yes
     2. No
102. Does the person avoid or dislike eye contact?

     1. Yes
     2. No
104. Does the person respond negatively to touch?

     1. Yes
     2. No
105. Does the person respond negatively to animals?

     1. Yes
     2. No
107. Please describe any triggers or sensitivities the person has
109. What can calm or soothe the person?
110. Any favorite toys, topics of discussion, objects, music, likes or dislikes?
114. Emergency Contact Information
116. First Name*
117. Last Name*
118. Email Address
120. Address*
122. City
123. State
124. Zip Code
126. Phone Number*
127. Cell Phone Number
129. Relationship to vulnerable person*
133. IMPORTANT - PLEASE READ BEFORE SUBMITTING FORM
135. Please review the following before completing, and submitting this form.

     Participation in this registry is VOLUNTARY.

     The information on this form will be added to the San Bruno Police Department's record management system and may be distributed to first responders in order to better care for you or your family members.

     We respect the right to privacy and will make every attempt to ensure that all personal information remains confidential, unless release of the information is required by law.

137. INFORMATION PROVIDED IS ACCURATE AND TRUTHFUL*

     I acknowledge that the information provided is accurate and truthful and submitted voluntarily for the purpose of assisting first responders in more effectively responding to a potential emergency involving the vulnerable person.

     1. I agree
139. USE AND SHARING OF INFORMATION*

     I consent to the use and sharing of this information for the above listed purposes.

     1. I agree
141. RESPONSIBILITY TO KEEP INFORMATION CURRENT*

     I acknowledge that it is my responsibility to update the information provided if there are changes.

     1. I agree
Leave This Blank:


143. 1. Receive an email copy of this form.
144. Email address

     This field is not part of the form submission.

145. Submit

* indicates a required field